Provider Demographics
NPI:1720228034
Name:BRAATEN, JILL R (RD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:BRAATEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:R
Other - Last Name:BRAATEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD/LD
Mailing Address - Street 1:500 W GRANT ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-1143
Mailing Address - Country:US
Mailing Address - Phone:651-345-3321
Mailing Address - Fax:
Practice Address - Street 1:500 W GRANT ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1143
Practice Address - Country:US
Practice Address - Phone:651-345-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2368133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered